PATIENT German Serrato DOB AGE SEX PRN 01/29/1985 35 yrs Male SG298088 FACILITY Juan Carlos Rondon MD PA T (954) 322-8985 F (954) 322-8981 3157 N University Drive Suite 103 Hollywood, FL 33024 ENCOUNTER NOTE TYPE SEEN BY DATE AGE AT DOS Not signed SOAP Note Carlos Pardo FNP-C, DISPENSING PRACTITIONER 09/25/2020 35 yrs Chief complaint Vertigo (Appt time: 4:00 PM) (Arrival time: 4:00 PM) Vitals for this encounter 09/27/20 8:39 PM Height 68.5 in Weight 184.36 lb Temperature 97.80 °F Pulse 96 bpm Respiratory rate 16 bpm O2 Saturation 99 % BMI 27.62 Blood pressure 115/72 mmHg Diagnoses Was diagnosis reconciliation completed? Yes, reconciliation performed Current ACUITY (H81.13) Benign paroxysmal vertigo, bilateral Acute (Z86.69) Personal history of other diseases of the nervous system and sense organs Chronic Historical ACUITY START STOP START STOP No historical diagnoses Drug Allergies Was medication allergy reconciliation completed? Yes, reconciliation performed Active SEVERITY/REACTIONS ONSET SEVERITY/REACTIONS ONSET No drug allergies recorded Food Allergies Active No food allergies recorded Environmental Allergies g Active SEVERITY/REACTIONS ONSET No environmental allergies recorded Medications Was medication reconciliation completed? Yes, reconciliation performed Active SIG START/STOP ASSOCIATED DX SIG START/STOP ASSOCIATED DX No active medications recorded Historical No historical medications recorded Subjective HPI: This is an initial visit. Mr. Serrato comes to my o ce c/o dizziness, light headache, unbalance sensation x last 1 day. Symptoms are similar to previous events (#3) that began on July 15th, 2018. Interventions the patient has tried have not provided any relief. Additional information: He was diagnosed with Vertigo, treated by MD with rst generation oral antihistamine + head exercises. Patient states that today he is feeling the same, despite of current treatment. Objective Physical Exam: Constitutional: Normal - Well developed. Eyes: Normal - Conjunctiva - Right: Normal, Left: Normal, Nystagmus Ears: Normal - Inspection - Right: Normal, Left: Normal Nose/Throat/Mouth: External nose - Normal Neck: Inspection - Normal. Active painful ROM - (+) pain, tenderness, sti ness Respiratory: Inspection - Normal. E ort - Normal. Vascular: Normal - Capillary re ll - Less than 2 seconds Abdomen: Inspection - Normal. Auscultation - Normal. Palpation - Normal Musculoskeletal: Cervical, Thoracic, Lumbar Spine - Inspection: Normal. Range of motion: Normal. Strength UE: Description - Upper extremity strength is normal: Bilateral. Strength LE: Description - Lower extremity strength is normal: Bilateral. Skin: Inspection: Normal Neurological: Bilateral Nystagmus Psychiatric: Normal. Orientation - Oriented to time, place, person & situation. Appropriate mood and a ect. Assessment Assessment: 1. Benign Paroxysmal Vertigo 2. History of Personal Vertigo Diagnoses attached to this encounter: (H81.13) Benign paroxysmal vertigo, bilateral Acute (Z86.69) Personal history of other diseases of the nervous system and sense organs Plan Plan: 1. Epley Maneuver 2. Meclizine 25 mg PO TID x 10 days 3. Follow up in 1 week or go to the nearest ER if symptoms persist or get worse. Screenings/ Interventions/ Assessments No screenings/interventions/assessments recorded.
